Addressing health workforce issues is one of the main challenges that EU health systems will have to face over the next decade. The COVID‑19 pandemic highlighted that the most important factor of a good-functioning health system is a robust, well-trained, and dedicated health workforce, but shortages and rigidities hampered responses to the pandemic. During the pandemic and in its aftermath, most EU countries have reported shortages of different categories of health workers. Based on proposed minimum thresholds of health worker densities to achieve universal health coverage, in 2022 EU countries faced a shortage of 1.2 million doctors, nurses and midwives. Looking forward, population ageing will continue to exert pressure on the demand for healthcare, while the ageing of the health workforce itself will increase the need to replace them with newly-trained workers. Several countries are looking at recruiting health workers from abroad to respond to current shortages, but this risks exacerbating shortages in countries of origin and may not be sustainable in the long run, as these countries strengthen their health systems and require more health workers domestically. EU countries can use three broad strategies to address health workforce shortages in the short and longer-term: 1) train more health workers (although this will take several years to yield results); 2) retain more health workers longer in the profession by improving working conditions; 3) support innovations in health service delivery to make a more effective use of the health workforce and new technologies.
Health at a Glance: Europe 2024
Abstract
The COVID‑19 pandemic has exposed the vulnerabilities of health systems across the European Union (EU), with one of the most pressing issues being the shortage of health workers. The stark reality witnessed during the first two years of the pandemic, where countries with more health and social care workers experienced fewer excess deaths (defined as deaths in excess of the historical baseline) compared to those with fewer workers, has underscored the critical importance of investing in securing an adequate, properly skilled workforce to nurture the resilience capacity of our health systems. The pandemic has not only exacerbated existing labour shortages, but also highlighted the growing challenges in attracting and retaining workers in the health sector, making it arguably the biggest challenge facing EU health systems today.
Concerns about the shortage of health workers in Europe are not new. This challenge has been primarily driven by the “double demographic” phenomenon of an ageing population coupled with an ageing health workforce. As noted in Chapter 2, the proportion of people aged 65 and over in the EU has risen from 16% in 2000 to 21% in 2023, and is projected to reach nearly 30% by 2050 due to rising life expectancy and declining fertility rates. This demographic shift is expected to greatly increase the demand for health and long-term care. At the same time, the health workforce itself is ageing, with large numbers of doctors and nurses retiring or due to retire in the coming years and needing to be replaced by younger professionals.
While promoting healthy ageing through effective public health and prevention policies can help mitigate some of the increased demand stemming from population ageing, addressing health workforce shortages remains paramount. The urgency of the challenge is compounded by the potential vicious circle observed in several EU countries in the aftermath of the acute phase of the pandemic: understaffing creates stressful working conditions, leading to increased resignations and declining interest in health professions. This risks creating a downward spiral where shortages beget further shortages over time. Decisive action is therefore needed to avoid this cycle and ensure the long-term sustainability of Europe’s health systems.
Against this background, this thematic chapter examines the complex issue of the shortage of health workers in the EU, offering a comprehensive overview of recent developments, current challenges and potential solutions. The chapter begins by examining the main drivers of supply and demand for health workers, followed by a detailed examination of past trends and current health workforce challenges across EU countries. It then investigates the root causes of these shortages and presents key policy components that should be incorporated into effective remedial strategies. These include enhancing health workforce planning to inform policy decisions, increasing the education and training of new doctors and nurses, improving working conditions to boost retention rates, and leveraging innovations to augment the productivity of health workers and optimise the use of their skills. While many countries are currently aiming to address their health workforce shortages by drawing at least partly on recruitment from other countries, this raises ethical issues when such recruitment occurs in lower-income countries that face even more acute shortages. It is also not a sustainable approach in the long run as the countries of origin develop their economies and health systems and will have greater demand and ability to retain more health workers.
Health workforce shortages have been a longstanding concern in most European countries, and in the aftermath of the COVID‑19 pandemic they have emerged as a mounting challenge that risks threatening the accessibility, quality and resilience of health services in several European health systems (OECD, 2023[1]). By definition, a shortage of health workers means that there is some imbalance between the demand and supply of workers. Many factors shape the demand and supply of different categories of health workers and may be influenced by policy actions to address such imbalances. Figure 1.1 presents a basic framework that illustrates the main factors affecting the supply and demand for health workers. On the supply side, it is based on a classic “stock and flow” model, where changes over time in the stock (or supply) of health workers are influenced by inflows and outflows. The inflows depend primarily on the entry of new graduates into the workforce and the immigration of foreign-trained workers (which can play an important role in some countries). The outflows include workers leaving the health workforce due to retirement, emigration or decisions to seek job opportunities in other sectors. The current supply of health workers is influenced by both the number of workers and the working hours (which can be measured through full-time equivalents). If for example the supply of health workers increases by 10% over a ten‑year period but the average working time of workers decreases by 10% as workers want to achieve a better work-life balance, then the supply of health workers in full-time equivalents remain unchanged. A range of policies can impact the supply of health workers, including education policies (such as subsidising medical/nursing education and setting more or less strict quotas on student admissions), policies affecting working conditions, working hours and pay, migration and retirement policies.
The demand for health workers is a derived demand for health services, which is driven by a complex interplay of demographic shifts, morbidity patterns, medical technology advances, GDP growth and budgets for health services (which, in turn, affect the capacity to recruit different categories of health workers and their pay rate). The demand for different categories of health workers also depends on the skill-mix and task sharing modalities in the delivery of health services – for example, the demand for physicians is partly determined by the availability of nurses and other professionals who can complement physician activity. Advances in medical technology are also a key determinant of the demand for health workers: for example, the development of new diagnostic tools, such as AI-powered imaging analysis, may reduce the demand for radiologists. Similarly, the growing adoption of telemedicine and remote monitoring technologies may alter the skill mix required in primary care, with a greater emphasis on digital literacy and communication skills among health professionals.
Addressing shortages of different categories of health workers requires a multi-pronged strategy targeting both supply-side policies (e.g. expanding education, increasing retention) and demand-side policies (e.g. making more effective use of the health workforce by changing skill-mix and supporting an effective use of technologies). The optimal policy mix will depend on each country’s specific circumstances. However, in all cases, a long-term, comprehensive workforce strategy is needed to ensure an adequate supply of health workers to meet the growing demand for health services across Europe. These strategies have to be regularly reassessed and updated to take into account changing circumstances affecting demand-side and supply-side factors.
Source: Adapted from OECD (2016[2]), Health Workforce Policies in OECD Countries: Right Jobs, Right Skills, Right Places, https://doi.org/10.1787/9789264239517-en.
1.3.1. The number of health workers, doctors and nurses has increased in nearly all EU countries over the past two decades
Despite concerns about a health workforce crisis, the health and social care sectors employ more workers now than at any time in history in most EU countries. In 2022, more than one in every ten jobs (10.1%) was in health and social care on average across EU countries, up from 8.5% in 2002 (Figure 1.2). In most Nordic countries, the Netherlands and Belgium, more than 14% of all jobs were in health and social care work. However, despite this growth, many countries – even those with some of the most well-resourced health systems – are grappling with the challenge of ensuring an adequate and sustainable supply of health workers to meet future needs. The example of Norway illustrates the importance of increasing health workforce productivity in light of supply constraints (Box 1.1). By contrast, the share of health and social care workers remains much lower in countries such as Cyprus, Bulgaria and Romania, accounting for less than 6% of total employment.
Note: The EU average is weighted.
Source: Eurostat based on Labour Force Survey data (lfsa_egana, lfsa_egan2).
Like all European countries, Norway’s healthcare system is under increasing pressure from the combination of an ageing population and a growing shortage of health workers. Recognising the urgency of the situation, in December 2021 the Norwegian Government appointed a Healthcare Personnel Commission to conduct an in-depth analysis of the country’s looming workforce challenges.
The report from this Commission, tabled in February 2023, offers a sobering assessment of Norway’s ability to meet its future health workforce needs. Norway’s health sector (excluding social work activities) is the country’s largest employer, employing over 400 000 people, or more than 15% of the total workforce – the highest proportion in Europe. The sector’s workforce has grown rapidly, more than tripling since the early 1970s, driven by strong economic growth, medical advances and an ageing population.
However, this growth trajectory is set to collide with a demographic shift that will simultaneously increase demand for healthcare while shrinking the available labour pool, placing an ever-greater burden on a dwindling share of workers. The Commission’s analysis suggests that there is little scope for the health sector to increase its already large share of the workforce without drawing talent away from other priority sectors of the economy. The report also advises against large‑scale recruitment of health workers from abroad as a solution, stressing that reliance on foreign workers would introduce fragility into the system and be irresponsible from a global perspective.
To meet this challenge, the Healthcare Personnel Commission recommends a multi-pronged strategy aimed at limiting growth in the health workforce to no more than 0.5% per year, while at the same time increasing productivity of existing human resources through increased task shifting, technology use, service redesign and improved care integration. In particular, the report calls for a fundamental change in societal attitudes towards healthcare, emphasising the need to set priorities and set realistic expectations about the level of service provision. The Healthcare Personnel Commission stresses the need for a public debate on the difficult trade‑offs that are inevitable in light of projected fiscal and demographic developments.
Source: Healthcare Personnel Commmission (2023[3]), Time for action: personnel in a sustainable health and care service, www.regjeringen.no/.
The number of doctors and nurses per capita has increased substantially over the past two decades in most EU countries. However, this does not mean that shortages have decreased if the demand for doctors and nurses has increased even more during the same period.
On average across EU countries, there were 4.2 doctors per 1 000 population in 2022, up from 3.1 in 2002 and 3.6 in 2012 (Figure 1.3). The growth in the number of doctors has been particularly rapid in Greece and Portugal, but it is important to note that the data for these two countries relate to all doctors licensed to practice (therefore including a large number who may no longer practice but have nonetheless kept their licence). Austria, Cyprus and Norway had the highest number of practising doctors per population with about 5 doctors per 1 000 population or more. The number of doctors per population was lowest in Luxembourg (although the latest data dates back to 2017) and France (although the number does not include physicians-in-training, resulting in an under-estimation compared to other countries).
Notes: The EU average is unweighted. 1. Data refer to all doctors licensed to practice, resulting in a large over-estimation of the number of practising doctors. 2. Data include not only doctors providing direct care to patients, but also those working in the health sector as managers, educators, researchers, etc. (adding another 5‑10% of doctors). 3. Medical interns and residents are not included. 4. The latest data refer to 2017 only. 5. The data for Belgium starts in 2013 and for Cyprus, Ireland and the Netherlands in 2014 to avoid breaks in time series (the last data point for Ireland relates to 2023 to avoid a break in 2022).
Source: OECD Health Statistics 2024; Eurostat (hlth_rs_prs2).
Nurses represent the most numerous category of health workers in nearly all EU countries. However, it is not easy to collect data on nurses across countries because the distinction between different categories of nurses is not always clear and there are also blurring lines (“grey zones”) between some categories of nurses and personal care workers/healthcare assistants who are not recognised as nurses (Box 1.2).
Defining who is a nurse (and who is not a nurse) for the purpose of international data collection is not as easy as it might seem at first sight. The main issue is that in several countries the distinction between different categories and levels of nurses is not clear-cut, and there are also blurring lines in qualifications, job titles and tasks between some categories of nurses and personal care workers /healthcare assistants.
The OECD/Eurostat/WHO-Europe Joint Questionnaire on Non-Monetary Healthcare Statistics collects data on the two broad categories of nurses that are identified in the International Standard Classification of Occupations (ISCO‑08): “professional nurses” and “associate professional nurses”. Data on personal care workers/healthcare assistants are collected separately (based also on the ISCO classification).
In the EU, the first category of “professional nurses” has been defined as those who have a level of qualifications meeting the EU Directive on the recognition of professional qualifications for general nurses (i.e. at least three years of study or 4 600 hours of theoretical and clinical training according to Directive 2013/55/EU). The second category of “associate professional nurses” includes all other categories of nurses that are recognised as such in each country. Only about one‑third of EU countries report data for this second category. However, a few countries are not able to make a clear distinction between these two broad categories of nurses and only report the total of nurses without any distinction.
It is also important to bear in mind that a comprehensive assessment of the nursing-related workforce would also take into account the support provided by personal care workers/healthcare assistants. For example, in some countries that have below average numbers of nurses such as Italy and Spain, a large number of personal care workers/healthcare assistants provide assistance to nurses and patients.
The number of nurses has increased over the past decade in most EU countries. On average across EU countries, there were 8.4 nurses per 1 000 population in 2022, up from 7.3 in 2012 (Figure 1.4).1 Norway, Iceland, Finland, Ireland and Germany had the highest number of nurses per capita in 2022, with at least 12 nurses per 1 000 population. By contrast, Greece had the lowest number of nurses per capita among EU countries, but the data only include nurses working in hospitals. The number of nurses per capita was also relatively low in Latvia, Bulgaria, Cyprus and Hungary. The Hungarian Government has increased substantially the remuneration of nurses in recent years to increase attractiveness and retention in the profession (see indicator on “Remuneration of nurses” in Chapter 7).
Note: The EU average is unweighted. Professional nurses refer to nurses with an education level meeting the EC Directive on the recognition of professional qualifications (a minimum of 3 years of postsecondary education for general nurses and at least an equivalent level of education for specialist nurses). Associate professional nurses include all other categories of nurses that are recognised in some countries. Some countries are not able to make a clear distinction between these two main categories. 1. The latest data for Luxembourg refer to 2017 only. 2. The data for France and Poland starts in 2013, for the Netherlands in 2014 and for Hungary in 2017 to avoid breaks in series.
Source: OECD Health Statistics 2024; Eurostat (hlth_rs_prs2).
Figure 1.5 shows the relationship between the number of doctors and nurses per 1 000 population across countries in 2022. The Nordic countries (with the exception of Finland), Austria, Germany and Czechia are characterised as having both a higher-than-average number of doctors and nurses per population. These are also countries that spend more than the EU average on health with the exception of Czechia (see indicator on “Health expenditure per capita” in Chapter 5).
By contrast, most Central and Eastern European countries are characterised as having lower-than-average number of doctors and nurses, and these are also countries that tend to spend less on health. Many countries in Southern Europe (e.g. Greece, Cyprus, Italy and Spain) have a higher-than-average number of doctors per population but lower-than-average number of nurses, suggesting a greater reliance on doctors to deliver health services. By contrast, some countries mainly in Western Europe (e.g. Belgium, Finland, Ireland, Luxembourg and the Netherlands) have a higher-than-average number of nurses but lower-than-average number of doctors, suggesting a greater reliance on nurses in delivering services. However, it is important to keep in mind that while EU averages can serve as useful benchmarks, they do not necessarily reflect the adequacy of health workforce supply in any given country.
Notes: The EU average is unweighted. The data on nurses include all categories of nurses (not only those meeting the EU Directive on the Recognition of Professional Qualifications). In Portugal and Greece, data refer to all doctors licensed to practice, resulting in a large overestimation of the number of practising doctors. In the Slovak Republic, data refer to professionally active doctors, resulting in a slight over-estimation. In Portugal and the Slovak Republic, data refer to professionally active nurses, resulting in a slight over-estimation. In Greece, the number of nurses is underestimated as it only includes those working in hospital. The data for Luxembourg refer to 2017 (latest year available).
Source: OECD Health Statistics 2024 (data refer to 2022 or the nearest year).
1.3.2. Most doctors, nurses, and other health and social care workers are women
Women constitute the majority of health and social care workers in all EU countries. On average across EU countries, 79% of health and social care workers were females in 2023, according to the EU Labour Force Survey.
Women have traditionally accounted for the bulk of nurses and healthcare assistants, and this continues to be the case nowadays. In 2022, they accounted for over 85% of all nurses on average across EU countries, a share that has been fairly stable over the past few decades. One of the main challenges to address nurse shortages is therefore to attract more men into the profession.
The proportion of female doctors has increased greatly in many countries over the past two decades, so that in the EU as a whole, more than half (53%) of doctors in 2022 were women, up from 45% in 2010. This growth was the sole contributor to the substantial increase in the number of doctors during that period as the number of male physicians decreased over time.
1.3.3. The average working hours of doctors has decreased over the past decade, while it has remained stable for nurses
While the number of doctors in headcounts has increased over the past decade in nearly all countries, the average working hours of doctors has decreased in most countries, so the increase in the number of full-time equivalents (FTEs) has been more modest. Part of this reduction is due to the feminisation of the medical workforce, but the working time of male doctors also fell over the past decade as many aim to achieve a better work-life balance. On average in the EU, male doctors worked 43.2 hours per week in 2022 (down from 44.3 hours in 2012), while female doctors worked on average 39.5 hours per week (down from 40.0 hours), often reflecting changes in work-life balance preferences and uneven family responsibilities. Nurses generally work fewer hours than doctors, but their working hours have remained relatively stable over the past decade on average in the EU (Figure 1.6).
Note: The EU average is weighted based on the number of doctors and nurses. The data include both employed and self-employed workers.
Source: Eurostat based on EU Labour Force Survey microdata.
1.3.4. The ageing of the health workforce requires efforts in training and retaining
The ageing of the physician workforce is a growing concern in many EU countries, with a substantial proportion of doctors nearing retirement age and a non-negligible number already beyond it. In 2022, over one‑third (35%) of doctors across EU countries were over 55 years old, with nearly half of EU countries having this proportion reach 40% or higher (Figure 1.7). Italy and Bulgaria are the two EU countries facing the most pressing concerns, with more than half of their physician populations aged over 55 and more than a fifth aged over 65. This age composition poses a dual challenge for the countries concerned, as they will need to train sufficient numbers of new doctors to replace those retiring over the next decade and simultaneously implement policies to encourage current doctors to continue working beyond the standard retirement age. In this context, flexible work-to-retirement arrangements can play a key role in retaining experienced doctors in the workforce longer.
While the proportion of nurses over 55 years old is generally lower compared to physicians in nearly all countries, ensuring an adequate supply of new nurses and improving retention rates of current nurses until standard retirement age remain nonetheless key issues to avoid an exacerbation of nurse shortages and to allow more experienced nurses to provide mentorship and training to new nurses.
Note: The EU average is unweighted and refer to countries for which data are available for each category of workers. The data for Luxembourg refer to 2017.
Source: OECD Health Statistics 2024; Eurostat (hlth_rs_phys).
1.3.5. The composition of the medical workforce has shifted towards specialists
Issues around the shortages of doctors often go beyond the overall number and relate more specifically to certain categories of doctors and their geographic distribution.
In many countries, the main concern about the shortage of doctors has been about a growing shortage of general practitioners (GPs), particularly in rural and remote areas, contributing to medical deserts. Whereas the overall number of doctors per capita has increased in all countries over the past two decades, the share of GPs has come down in most countries, reflecting reduced attractiveness of general medicine. This has happened despite the fact that a growing number of doctors are women who have traditionally been more inclined to go into general practice than men. On average across EU countries, only about one in five doctors were GPs in 2022, whereas two‑thirds were specialists (Figure 1.8). A few countries such as Portugal, Finland, Belgium and France, have been able to maintain a better balance between GPs and specialists, with GPs accounting for at least 30% of all doctors.
Note: The EU average is unweighted. 1. The category “Other doctors” includes other generalist (non-specialist) medical practitioners not considered GPs, recent medical graduates who have not yet started post-graduate specialty training and other doctors not further defined. 2. In Portugal, only about 30% of doctors employed by the public sector work as GPs in primary care – the other 70% work in hospitals. 3. The data for Luxembourg refer to 2017.
Source: OECD Health Statistics 2024; Eurostat (hlth_rs_prs2).
1.3.6. The uneven geographical distribution of doctors is a major barrier to access to care in peripheral regions
There also continues to be wide variations in the geographic distribution of doctors, resulting in medical deserts. In many countries, there is a particularly high density of doctors in national capital regions, reflecting the concentration of specialised services and physicians’ preferences to practice in national capitals. This is the case for example in Austria, Croatia, Czechia, Denmark, Hungary, Greece, Poland, Portugal, Romania and the Slovak Republic (Figure 1.9).
Note: The data refer to 2022, except for Denmark and Sweden (2021) and Finland (2020).
Source: Eurostat (hlth_rs_physreg) and OECD Regional Database.
Three recent EU-funded projects aimed to improve the understanding, measurement and potential policy actions to address different types of medical deserts (Box 1.3).
“Medical desertification” refers to the emergence of severely underserved areas where residents face major barriers to accessing needed health services. While various definitions of “medical deserts” exist reflecting different types of access issues, the concept typically encompasses geographical distance to healthcare facilities and providers, shortage of health professionals, and areas with ageing and declining or disadvantaged populations that make it difficult to attract and retain medical staff in such areas. Three EU-funded projects, which ran between 2021 and the first quarter of 2024, aimed to better understand, measure and address this medical desertification:
ROUTE‑HWF (Roadmap OUT of mEdical deserts into supportive Health WorkForce initiatives and policies) aimed to help EU countries reduce inequalities in healthcare access by supporting them in designing and implementing policies related to medical deserts. It developed a taxonomy of five distinctive types of medical deserts, guidelines on monitoring and measuring them, analysis of factors driving desertification, and a roadmap with a policy mix to address different types of medical deserts.
OASES (prOmoting evidence‑bASed rEformS) aimed at strengthening the capacity of health authorities in Cyprus, Finland, France, Hungary, Italy, Moldova and Romania to address medical deserts. It developed a methodology to measure spatial access and conducted pilot studies in participating countries to assess medical deserts and built consensus on mitigation strategies among stakeholders.
AHEAD (Action for Health and Equity: Addressing medical Deserts) aimed to reduce health inequalities by addressing the challenge of medical desertification in Italy, Moldova, the Netherlands, Romania and Serbia. Its goals were to achieve better access to health services in underserved areas and more equitable access to health workers by building knowledge, encouraging innovation in health service delivery, and applying a participatory approach to health policy making.
Countries have sought to address such medical deserts through policies based on financial incentives, health service redesign and digital solutions:
In France, where the term “medical deserts” was first popularised almost two decades ago, successive governments have implemented various initiatives to address the growing shortage or complete absence of GPs in certain regions. The main policy response has been the creation of multidisciplinary health homes, allowing GPs and other primary care providers to work in the same location, thereby mitigating the challenges associated with solo practice. By the end of 2023, a total of 2 500 such homes were in operation, with a target of reaching 4 000 by the end of 2027 (Ministère de la Santé et de la Prévention, 2024[4]). However, despite these efforts and the provision of various financial incentives for doctors to set up their practices in underserved areas, the measures do not seem to have been sufficient to resolve the issue (OECD/European Observatory on Health Systems and Policies, 2023[5]).
In Czechia, the Ministry of Health offers special subsidies to GPs to open offices in underserved areas, and health insurers provide higher payments to doctors serving less densely populated regions to attract and retain them in underserved areas (OECD/European Observatory on Health Systems and Policies, 2023[6]).
Spain has also taken steps to address medical deserts by promoting the adoption of digital health solutions, such as telemonitoring programmes, in combination with the introduction of advanced nursing practices without physicians (Dubas-Jakóbczyk et al., 2024[7]). Furthermore, the Spanish Government has launched initiatives to encourage medical staff to work in rural and sparsely populated areas, including investing in health centre infrastructure and deploying training programmes for medical students in rural settings – a practice which has however received some criticisms from Spain’s General Council of Physicians on the grounds that it risks hampering the professional development of young doctors (Consejo General Médicos, 2024[8]).
1.3.7. What do we know about current shortages of health workers in EU countries?
Despite the widespread concern about workforce shortages in most EU countries, there is a scarcity of robust data to accurately quantify the shortages of various categories of health workers at both national and subnational levels. This lack of data makes it difficult to determine to what extent these shortages might have worsened over time. Conventional economic theory suggests that unfilled or hard-to-fill job vacancies are a key indicator of shortages, but very few countries routinely collect and report data on this indicator.2 Another indicator that could potentially fill this gap is population-reported unmet healthcare needs due to a lack of available health workers or waiting times. However, the questions on unmet healthcare needs in population-based surveys are often limited to a few professional categories only (e.g. doctors and dentists), and do not provide a precise measure of the shortages of these health professionals.
During the COVID‑19 pandemic, the OECD collected data from its member countries on the shortage of various categories of health workers as part of a questionnaire to identify the main challenges countries faced in responding to the crisis. A total of 26 OECD countries, including 14 EU countries, responded to this questionnaire. As illustrated in Figure 1.10, the reported shortages varied significantly among the responding countries. Some countries, such as Austria, Portugal and Spain, reported shortages across a wide range of categories of health and long-term care workers, whereas other countries such as France, Germany and Luxembourg reported more specific shortages of certain categories of workers in certain settings, such as nurses and healthcare assistants in hospitals and/or long-term care facilities.
Note: This figure shows the country responses to the question: “Which categories of health and long-term care workers were particularly in short supply during the COVID‑19 pandemic?”
Source: OECD Resilience of Health Systems Questionnaire 2022 – adapted from Figure 10.5 in OECD (2023[1]), Ready for the Next Crisis? Investing in Health System Resilience, https://doi.org/10.1787/1e53cf80-en.
The European Employment Services (EURES) network’s most recent annual report on labour shortages and surpluses provides insights into the countries reporting shortages in various sectors, including the health and social care sector, for the period spanning 2022 and 2023 (European Labour Authority, 2024[9]). The information on occupations in shortages, as provided by the EURES National Co‑ordination Offices in the 27 EU countries and Norway, draws on diverse sources and indicators, including public employment services’ administrative data, national lists of occupations qualifying for work permits and national employment barometers. The most recent findings reveal that 75% of the surveyed countries (21 out of 28) reported a shortage of doctors (either generalists or specialists) in the second half of 2022 and first half of 2023, about 60% (16 countries) reported a shortage of nurses and 55% (15 countries) a shortage of healthcare assistants (Figure 1.11). Although this approach effectively identifies the number of countries reporting shortages in specific health worker categories, it does not provide any precise quantitative assessment of the magnitude of these shortages.
Note: Data refer to the second half of 2022 and/or the first half of 2023, based on 28 reporting countries (EU27 and Norway).
Source: European Labour Authority (2024[9]), Report on labour shortages and surpluses 2023, https://data.europa.eu/doi/10.2883/973861.
Previous OECD work (Morgan and James, 2022[10]) provided an order-of-magnitude estimate of the shortage of health workers in OECD countries based on a set of minimum thresholds of health worker densities proposed by the Institute of Health Metrics and Evaluation (IHME). The same methodology can be applied to EU countries to provide an approximation of health workforce shortages in the region. Following a systematic analysis of the Global Burden of Disease Study 2019 to measure health workforce requirements in relation to universal health coverage (UHC), the IHME derived levels of health worker density required to achieve a performance target of 90 out of 100 on the UHC effective coverage index. The thresholds of 3.54 doctors and 11.45 nurses and midwives per 1 000 population were adopted in this study (Haakenstad et al., 2022[11]). Based on these minimum thresholds set by IHME, EU countries had a shortage of approximately 1.2 million doctors, nurses and midwives in 2022.
It is important to note that these estimates are based on a set of minimum thresholds that do not comprehensively capture the specific health workforce needs of individual countries, as several factors can influence the health worker densities required to meet the healthcare needs of each country. Nevertheless, this estimate offers a valuable starting point for understanding the scale of health worker shortages in the EU, also highlighting the need for concerted efforts to address this challenge.
Workforce planning and forecasting in the health sector is particularly important given the time and cost involved in training new doctors and other highly skilled health professionals. In a context of rising demand for healthcare together with budget constraints on governments, the development of more sophisticated health workforce planning is needed to guide policy making, notably with regard to student intakes in various medical specialties (including general medicine) and other health professions. These decisions on the required inflows of new doctors and nurses should be made in light of current and projected outflows from the workforce as well as possible innovations in skills mix and substitutions of certain categories of health workers by other categories or by technologies under new health service delivery models.
The first step of any robust health workforce planning exercise is to have good data about the current health workforce situation and recent trends. Without good data on recent trends and the current situation, it is impossible to make any accurate projections about the future. The data currently available in many EU countries have serious limitations in measuring several important aspects regarding the current supply of different categories of health workers, in particular the outflows (e.g. early exit from the occupation, effective retirement age and emigration). As noted in the previous section, currently available data also often cannot measure any current imbalance between the supply and demand for different categories of health workers, so most health workforce projection models of doctors and nurses start by making the convenient (but unsatisfactory) assumption that there is currently no shortage (or potential surplus). Data improvements are needed to allow health workforce planning models to assess more reliably recent trends, the current situation and the future outlook for all the main variables affecting the supply and demand for different categories of health workers as illustrated in the analytical framework presented in Figure 1.1.
The European Commission has supported over the past 10 years a number of projects and Joint Actions on health workforce planning and forecasting to provide opportunities for countries to effectively learn from each other and identify good practices. The current Joint Action HEROES (HEalth woRkfOrce to meet health challEngeS), which started in early 2023 and is expected to end in 2026, involves 21 countries. It has four main objectives: 1) develop databases, data collection, analysis, linkages and sources on health workforce supply and demand; 2) develop forecasting tools and planning methodologies to address health workforce future challenges; 3) develop and enhance skills and capacities for effective management of health workforce planning systems at national and regional levels; and 4) engage stakeholders for successful and sustainable health workforce governance (HEROES Joint Action, 2023[12]).
The European Commission (through its Joint Research Centre) will also release in December 2024 a series of projections about the possible future supply and demand for doctors and nurses across all EU countries over the coming decades based on different scenarios (Box 1.4).
The Joint Research Centre (JRC) of the European Commission has developed a Supply ANd DEMand model for the healthcare workforce (SANDEM) to project the evolution of the supply and demand for health workers across the 27 EU countries up to 2071, focussing in particular on doctors and nurses.
The goal of the SANDEM model is to complement national health workforce planning with a series of “what if” scenarios with a long-term EU perspective, rather than projecting any specific number of doctors and nurses in each country. While reflecting national differences in the structure of the health workforce and general population trends, the model does not aim to provide any “gold standard” in terms of provider-to-population ratio. The model also remains at a relatively high level of aggregation and does not consider regional variations in the supply and demand for doctors and nurses, nor does it include a breakdown by medical specialty.
On the supply side, SANDEM uses a standard stock-and-flow model to characterise the medical and nursing workforce in terms of size and age structure. The model assumes that current trends in dropouts, retirements and migration will remain the same in the future, while allowing changes in the number of new graduates to respond to changes in demand.
On the demand side, the model includes several scenarios that combine demographic projections with individuals’ healthcare needs. The “population” scenario is based on a provider-to-population ratio that assumes that the only driver of health workforce demand is population size. The “utilisation” scenario goes a step further and estimates changes in demand using data on past trends in healthcare utilisation by age group based on two different epidemiological scenarios. In the “disease burden” scenario, age‑specific healthcare needs are assumed to remain the same in the future, while in the “healthy ageing” scenario they are assumed to decrease over time.
The model relies mainly on data from Eurostat, WHO and OECD. Data gaps are addressed by using some approximations. The main challenges relate to the lack of data on outflows from the health workforce (e.g. emigration, dropout and effective retirement age). One of the recommendations is to improve the collection of data on migration patterns of health professionals by distinguishing more clearly the emigration of health workers who are both foreign born and foreign trained from the internationalisation of medical education, reflecting the fact that a significant number of international students move temporarily to other countries to obtain a first medical degree before returning to their home country to complete their training and work. More basic data issues also relate to the lack of data on the current stock of practising doctors and nurses in some countries, and the inclusion of different categories of nurses at the national level and in international data collections.
The results from the SANDEM projection model are expected to be released by the end of 2024.
Source: Bernini, A., Icardi, R., Natale, F. and Nédée, A. (2024[13]), Supply and demand model for the healthcare workforce in the EU27 – Data sources and model structure, https://data.europa.eu/doi/10.2760/957386.
It is important to bear in mind that health workforce planning is inherently subject to uncertainty, precluding definitive long-term predictions. Health workforce planning models need to be continuously developed and regularly updated to take into account the availability of more recent and better data, changes in demographic and non-demographic factors that may affect the supply and demand for different categories of health workers, and the effects of any new policies that may affect the skill mix in health service delivery and the demand for different categories of health workers, as outlined in the analytical framework above (Figure 1.1).
One of the main policy levers to increase the supply of doctors and nurses is to increase the number of students in medical and nursing education programmes, although there is a time lag of several years between any decisions to increase student intakes and the completion of their studies (about 8‑12 years for doctors depending on the specialisation and at least 3 years for “professional” nurses). Determining what may be the “right” number of student intakes and graduates in medicine and nursing is complex and should be guided by robust health workforce planning.
1.5.1. Most EU countries have already recognised the need to train more doctors and nurses
Most EU countries had already taken steps to increase the number of students in medical and nursing education programmes before the pandemic as reflected by the growing number of medical and nursing graduates over the decade from 2012 to 2022. This is one of the main reasons why the number of doctors and nurses has increased in most countries during that period. The increase in the number of medical graduates was stronger than in nursing graduates. Across the EU, the number of new medical graduates increased at an average annual rate of over 3.5% between 2012 and 2022, while the number of nursing graduates increased at a more modest rate of about 0.5% per year. Part of the explanation for this slower growth rate is that the dropout rate from nursing education programmes is, in most countries, higher than from medical education programmes. In 2022, there were 15.5 medical graduates and 37.5 nursing graduates per 100 000 population in the EU as a whole, up from 11.1 medical graduates and 36.0 nursing graduates per 100 000 population in 2012.
The number of new medical graduates varied significantly across EU countries in 2022, ranging from about 12 per 100 000 population in Slovenia, Estonia and Germany to over 24 per 100 000 population in Ireland, Romania, Latvia, Malta and Bulgaria (Figure 1.12). Countries producing the most medical graduates relative to population size, such as Bulgaria, Romania and Ireland, largely reflect the success of medical schools in these countries to attract international students. This internationalisation of medical education has been facilitated by the EU Directive on the recognition of professional qualifications that allows automatic recognition of medical diplomas obtained in EU/EEA countries. While these provide opportunities for students to study medicine in another country, in most cases these international students leave the country after obtaining their first medical degree due to limited postgraduate specialty training opportunities or better career prospects in their home countries (OECD, 2019[14]).3
The number of new nursing graduates also varied widely across EU countries in 2022. Cyprus and Bulgaria – which also have among the lowest numbers of practising nurses – had the fewest graduates at less than 10 per 100 000 population. Romania and Greece topped the ranking with rates over 100 graduates per 100 000 population, though about 90% of these completed vocational training programmes below the EU Professional Qualifications Directive’s minimum requirements for general nurses. Norway, Iceland, Finland, Croatia and the Netherlands also had a relatively high number of nurse graduates in 2022, with more than 60 graduates per 100 000 population (Figure 1.12).
Notes: The EU average is weighted. The data relate to 2022 or most recent year available. The data on nursing graduates include graduates from programmes that are meeting the EU Directive on the recognition of professional qualifications as well as other nursing programmes at the national level. Luxembourg has no medical graduates as it launched its first full medical degree programme in 2020.
Source: OECD Health Statistics 2024; Eurostat for medical graduates (hlth_rs_grd2).
After the pandemic, many EU countries have decided to increase the number of students admitted in medical and nursing education programmes, although it is too early to see the results of these policy decisions in terms of the number of new graduates. Student intakes in medical education programmes have increased greatly in recent years in countries such as France, Italy and Poland. The increase in Germany has been more modest (Figure 1.13).
Sources: France: ONDPS; Germany: Education and Culture (Students at Universities reports); Italy: Ministry of University and Research; Poland: Ministry of Health (Admissions in Medicine and Dentistry annual reports).
1.5.2. Fewer young people seem interested in careers in health, calling for greater efforts to increase attractiveness
While many countries have recognised the urgent need to train more doctors, nurses and other health workers to address shortages, increasing the education and training capacity will prove ineffective if there is not a sufficient pool of qualified and motivated candidates to fill the additional training places available. According to the latest data from the Programme for International Student Assessment (PISA) survey, in about half of EU countries, health sector jobs have become less attractive to 15‑year‑old students. By comparison, the share of students aiming for careers as information and communications technology (ICT) professionals increased in nearly all countries (Figure 1.14).
Notes: The EU average is unweighted. Health professions includes doctors, nurses, midwives, dentists and other health professions. ICT professions refer to jobs such as software and web developers. Luxembourg did not participate in PISA 2022, while data for Cyprus are not available for this variable. Countries are ranked in descending order of the change between 2018 and 2022 in the percentage of students expecting to work as health professional.
Source: Adapted from OECD publication “PISA 2022 Results (Volume II): Learning During – and from – Disruption”, 2023.
While becoming a doctor still remains a very popular career aspiration among 15‑year‑olds, interest in nursing has always been less popular and has decreased in many countries between 2018 and 2022. On average across EU countries, less than 2% of 15‑year‑olds expected to become nurses in 2022, a proportion four times lower than those aspiring to become doctors. This contrasts with the actual composition of the health workforce as there are two times more nurses than doctors on average across EU countries (see indicator “Availability of nurses” in Chapter 7). Interest in pursuing a career in nursing has diminished in over half of EU countries. This reduction was particularly marked in some Nordic countries (Norway, Denmark and Finland to a lesser extent), Ireland, Czechia, Hungary and Romania (OECD, 2024[15]).
Data on applications to nursing education programmes also show that, following a brief increase during the onset of the pandemic, the number of applications has been decreasing in recent years in countries like Ireland and Italy. If the decline in applications continues, it will become increasingly difficult (if not impossible) to fill all available places (Figure 1.15).
Notes: In Ireland, the data on applications refer to students who ranked nursing as their first preference while the admissions data refer to the number of offers that have been accepted by students. The data include both nursing and midwifery programmes.
Source: Ireland: Central Applications Office; Italy: Conferenza Nazionale Corsi di Laurea delle Professioni Sanitarie.
One of the main reasons for the relatively low interest in the nursing profession is that it almost only attracts females. Results from PISA 2022 show that over 85% of 15‑year‑old students expecting to work as nurses are girls in most EU countries. A continuing challenge in all countries is to address the persistent stereotype that places nursing as a profession suited primarily for women. Addressing this bias requires efforts to change perceptions of traditional gender roles and better career guidance (OECD, 2024[15]).
1.5.3. Improving the quality of initial education and continuous professional development also matters to meet new skill requirements in the health sector
Beyond the sheer numbers of students admitted in medicine and nursing education programmes, it is also important to consider the types and quality of initial education and training that students are receiving, as well as opportunities for continuous professional development throughout the careers of doctors and nurses. The European Commission has launched a number of initiatives to address skills gaps in the European health sector (Box 1.5).
The COVID‑19 pandemic not only highlighted the critical importance of a skilled and resilient health workforce but also accelerated the adoption of digital health solutions and emphasised the need for sustainable, environmentally-friendly practices in the health sector. In response to these challenges, the European Commission launched two key initiatives in recent years.
The first initiative, launched in 2021, is the Skills Partnership for the Health Ecosystem (https://pact-for-skills.ec.europa.eu/about/industrial-ecosystems-and-partnerships/health_en). This initiative includes three large‑scale partnerships: a skills partnership focused on health workers, a skills partnership in the long-term care sector, and a skills partnership for the health industry. These partnerships aim to foster collaboration among stakeholders to address skills gaps and build a future‑ready health workforce. Their objectives encompass mapping current and future skills needs in the health sector, aligning education, training and employer needs at regional/EU level, facilitating cross-border mobility and recognition of qualifications, and promoting continuous professional development.
The second initiative, the Be Well Blueprint (https://bewell-project.eu/), launched in December 2022, focuses on upskilling and reskilling the European health workforce for the digital and green transition. Key activities include collecting in an easily accessible monitor existing upskilling/reskilling initiatives, developing and piloting comprehensive curricula and training programmes, and developing and launching a skills strategy for health workers focused on digital and green skills.
The return on investment in education and training will be lost if newly-trained doctors, nurses and other health workers don’t end up working in their profession for most of their working lives. Increasing the retention rates of current doctors, nurses and other health workers is key also to avoid a vicious circle whereby more workers leaving the sector would result in growing shortages and increased workloads and pressures on remaining staff, followed by more resignations and even greater shortages.
The quality of jobs plays a central role in the decision of people to stay in their current job or to leave. The OECD Job Quality Framework distinguishes three complementary dimensions of what makes a “good job”: 1) earnings (or remunerations) (discussed in Section 1.6.3), 2) labour market/job security, and 3) the quality of the work environment. This latter dimension includes several non-monetary aspects of job quality (OECD, 2024[16]).
1.6.1. The pandemic led to a deterioration of the working conditions for many health workers, but evidence of a “great resignation” is limited
The Eurofound’s 2021 European Working Conditions Telephone Survey (EWCTS) has gathered data on several aspects of the quality of jobs as it relates to the quality of the work environment of workers in all sectors of the economy, including the health and long-term care sector. Using a methodology developed by the OECD, the data from the EWCTS survey can be used to compare job demands or strains (which affect workers negatively) and job resources (which affect workers positively). When workers have more demands/strains than resources, they experience poorer job quality.
In 2021, therefore in the context of the pandemic, almost half of workers in the health sector (48%) and long-term care residential sector (47%) reported high levels of job strain on average in EU countries, a much higher proportion than workers across all sectors (30%). Looking at specific occupations, job strain was about two times higher among nurses (61%) and personal carer workers (55%) than across all occupations on average across the EU (Figure 1.16).
Notes: Job strain levels are calculated as the gap between job demands (6‑7 indicators) and resources (8 indicators). “Strained (extreme)” represents a >50% excess of demands over resources, “Strained (high)” a 25‑50% excess, and “Strained (moderate)” up to 25% excess. Where resources exceed or match demands, categories range from “Resourced (low)” (<25% resource advantage), “Resourced (moderate)” (25‑50% resource advantage) to “Resourced (high)” (>50% resource advantage). The nurses’ category also includes midwives.
Source: Eurofound (2021[17]), Working conditions in the time of COVID‑19: Implications for the future, https://doi.org/10.2806/357794.
In jobs with difficult working conditions, health and safety at work risks can be an additional factor contributing to lower job quality and retention, and greater shortages. Data from the EWCTS survey show that the highest levels of health and safety at work risk in 2021 were reported by nurses (69%), truck and bus drivers (53%), doctors (51%) and personal care workers (50%) (European Commission, 2023[18]). Additionally, the lack of flexibility in work schedules contribute to increased strain on workers, further impacting job satisfaction and retention.
While the OECD Job Quality Framework assumes that most workers prefer more over less job security, a significant number of newly-trained but also more experienced doctors and nurses have opted in recent years to take on temporary jobs – either via interim agencies or as self-employed – rather than seeking permanent employment from hospitals or other employers in the health sector. Greater job security may be less of an issue for people working in occupations where considerable shortage prevails and who are confident that they will find a temporary job, which may provide them with greater earnings and more flexibility over work schedules (Box 1.6). Addressing this issue is important not only for individual hospitals or other healthcare employers, but also to reduce cost pressures on the health system as a whole. However, there is no quick solution to this issue.
Like other industries, the health sector uses temporary staff to overcome momentary workforce shortages and to deal with unexpected increases in demand, as seen during the COVID‑19 pandemic. However, recent evidence suggests that these working arrangements have become more systematic and that a growing number of health workers actually prefer to be hired by interim agencies that “rent out” health workers to hospitals and other healthcare providers for short time periods. The normalisation of these employment situations has serious consequences from an organisational perspective as well as cost implications. It increases costs for hospitals and other health facilities and can generate tensions in the workplace, as doctors and nurses doing the same jobs are often paid more when employed by an interim agency than being regular hospital staff and may also have more desirable working schedules. In recent years, this trend has caught on in many European countries and beyond.
In France, hospitals have increasingly relied on interim doctors and nurses to fill vacant posts in emergency departments and other hospital units over the past few years. Reports suggest that interim doctors can earn 2‑3 times more than their counterparts with a regular contract with the hospital, while interim nurses are able to earn about 30% more. Interim staff also have much more flexibility to choose their working hours than regular staff. The government has adopted some regulations regarding the maximum amount that hospitals should pay interim doctors, although doctors are often in a position to negotiate a higher pay. A recent report by the French Auditing Court pointed out that between 2017 and 2022 the total costs of interim doctors for public hospitals increased by 25% to reach EUR 147.5 million, while the number of interim doctors increased by 23% over the same period.
In Germany, the costs associated with interim staff in hospitals (doctors and other health workers) reached nearly EUR 2.9 billion in 2022, double the costs seen in 2015. In 2022, around 33 000 staff working in hospitals had no employment relationship with hospitals, roughly double the number of 2010. Interestingly, this trend is nearly entirely driven by non-doctors.
The use of temporary contracts in the health sector in Spain also remains an issue, having increased to nearly 42% of all health workers in 2020 during the peak of the pandemic, up from 28% in 2012. A new regulation adopted in 2022 aims to reduce the use of temporary contracts by restricting their use to specific circumstances, imposing time limits on their duration and promoting the conversion of long-term temporary staff into permanent positions.
Sources: France : Cour des Comptes (2024[19]), Observations définitives Intérim médical et permanence des soins dans les hôpitaux publics - exercices 2017-2022 [Final observations medical interim and permanent care in public hospitals - financial years 2017-2022]; Germany: Statistisches Bundesamt (2024[20]), Hospitals in Germany - Federal Statistical Office, https://www.destatis.de/; Spain: OECD/European Observatory on Health Systems and Policies, (2023[21]), Spain: Country Health Profile 2023, https://www.doi.org/10.1787/71d029b2-en.
Results from health staff surveys conducted during the COVID‑19 pandemic in some EU countries showed a perceived degradation of working conditions, growing job dissatisfaction and intention to leave jobs. For example, in Belgium, the proportion of health workers expressing an intention to leave the profession increased markedly in 2021 to reach 28% by September 2021, up from less than 10% before the pandemic (Sciensano, 2021[22]).
During the second year of the pandemic in 2021, the term “great resignation” was coined in the United States to refer to the growing number of frontline workers in the health sector as well as in other sectors who were resigning at that time because of job dissatisfaction and possibly reflecting also some changes in people’s work-life balance preferences. It is hard to get reliable data from most EU countries to measure to what extent there might have been any “great resignation” of health workers in the aftermath of the pandemic because most European countries do not have the equivalent of the American Job Openings and Labour Turnover Survey that can be used to measure resignation (quit) rates. Sweden is an exception.4
The available survey data from the United States and Sweden show fairly similar trends in resignation rates from the health and social care sector before and after the pandemic (Figure 1.17). While in the two countries there was an increase in quit rates from the health and social care sector in 2021, these resignation rates decreased in the United States in 2022 while the reduction in Sweden occurred a bit later in 2023. The hiring (or recruitment) rates in the two countries show in fact greater differences. In the United States, the hiring rates have been steadily higher than the quit rates, thereby explaining the steady growth in employment in health and social care in recent years. By contrast, in Sweden, the hiring and quit rates have fluctuated from year-to-year, with the hiring rates being generally lower than the quit rates between 2018 to 2023. This was associated with a reduction in total employment in the health and social sector in Sweden during that period, which was driven by a sharp drop in employment in social care, while employment in healthcare continued to increase.
Notes: Sweden data refer to employees with a permanent employment contract who have resigned as a share of the total number of permanent employees in the health and social care sector. Data is presented as a 3‑period moving average.
Source: U.S. Bureau of Labor Statistics (2024[23]), Job Openings and Labor Turnover Survey, www.bls.gov/jlt/; Statistikmyndigheten (2024[24]), Kortperiodisk sysselsättningsstatistik [Short-term employment statistics], www.scb.se/.
Available data from other European countries, such as Ireland and the United Kingdom, also indicate that there was an increase in exit rates of public sector employees (from HSE and NHS) following the pandemic in 2021 and 2022, but the exit rates started to drop in 2023, suggesting that this may have been a transitory event (Health Service Executive, 2023[25]; NHS England, 2024[26]).
A significant proportion of health workers reported symptoms of anxiety, depression and burnout during the pandemic, with these symptoms often increasing as the pandemic went on. For example, over half of nurses, caregivers and other health workers in Belgium reported being under pressure and stress in March 2021, while 40% reported having mental health issues (Sciensano, 2021[22]). In France, over half (54%) of nurses working in public facilities reported in December 2021 being in burnout, and that this negatively impacted the quality of care provided and increased their intention to leave the profession in the short term (Ordre National des Infirmiers, 2022[27]). The EU-funded project METEOR, which ran from 2021 to 2024, aimed to measure the mental health of hospital workers and to provide a set of recommendations to improve working conditions and retention rates (Box 1.7).
The METEOR (Mental Health: Focus on Retention of Healthcare Workers) project, funded by the EU Health Programme between 2021 and the first quarter of 2024, aimed to assess the mental health of health workers and to improve job retention. The project conducted surveys in hospitals in four EU countries (Belgium, Italy, the Netherlands and Poland) and organised stakeholder workshops to develop policy recommendations to improve the working conditions of hospital workers and retention rates. In 2022, on average across participating countries and hospitals, only 13% of doctors and 16% of nurses were satisfied with their job, while about a quarter of both categories of workers reported emotional exhaustion and depersonalisation. Nonetheless, the intention to leave the profession remained low (9% among doctors and 13% among nurses).
One set of recommendations from the project relates to providing greater professional and personal support. This includes fostering interprofessional collaborations, supporting flexible work schedules, facilitating task sharing and the deployment of healthcare assistants to allow nurses to focus on their core patient-related duties, ensuring a stable and supportive environment and establishing psychological support services.
Another set of recommendations related to training and coaching, including recommendations such as putting in place onboarding and mentorship programmes, developing leadership programmes, implementing employee evaluations, encouraging peer supervision groups focused on stress and mental health in the workplace, and promoting lifelong learning and digital literacy among staff.
The third key area of recommendations was about regulation, including promoting adequate staffing levels and manageable workloads that support high-quality care at all times, enhancing job security, minimising bureaucratic burdens, addressing discrimination and bullying, and protecting workers against verbal abuse and aggression.
The fourth area focused on investment and providing flexible financial support. Recommendations included investing in new technologies that can help automate or simplify administrative tasks, allowing greater flexibility in funding allocation for hospital managers, and investing in more up-to-date equipment to improve quality of care and workers’ job satisfaction.
Source: https://meteorproject.eu/.
Post COVID‑19 condition – commonly referred to as long COVID – also presents a significant challenge to health workforce capacity. Health workers face elevated risk of developing this debilitating condition due to increased occupational exposure and the sector’s predominantly female workforce, as women appear to be more susceptible to long COVID (Expert Panel on effective ways of investing in health (EXPH), 2022[28]). The UK Office for National Statistics (ONS, 2023[29]) identified health workers as having the second-highest prevalence of long COVID, surpassed only by long-term care workers. Multiple studies have documented how long COVID reduces health workers’ ability to perform their duties (Cruickshank et al., 2024[30]).
The European Commission has announced in September 2024 a new contribution agreement with the WHO Regional Office for Europe to support EU Member States in retaining nurses in health systems and making the profession more attractive. The agreement, funded with EUR 1.3 million from the EU4Health programme, will involve activities across all EU Member States over a three‑year period. Particular focus will be given to those countries with significant shortages in health workers, and specifically shortages in nurses. Through co‑operation with Member States, nurses’ organisations and social partners, the initiative will be tailored to specific needs at national and sub-national level. The funding will include creating recruitment action plans, mentoring programmes to attract a new generation of nurses, strategies to improve the health and well-being of nurses, and implementing training opportunities and actions to ensure the health workforce can reap benefits of the digital transformation (European Commission, 2024[31]).
As part of another project funded by the European Commission, WHO-Europe has launched in October 2024 a survey to assess the mental health and well-being of health professionals across the 27 EU countries, Iceland and Norway. The survey aims to gather data to better understand the challenges doctors and nurses face in their work environments, including questions related to job satisfaction and intention to leave job (WHO-Europe, 2024[32]).
1.6.2. Retaining experienced doctors for longer in the workforce
The ageing of the physician workforce is a growing concern in many EU countries. As shown above in Figure 1.17, 40% of doctors in almost half of the EU countries were over 55 years old in 2022, raising concerns about a potential large wave of retirements in the coming years. This situation could aggravate current workforce shortages, particularly if there is an insufficient inflow of newly-trained doctors to replace those retiring.
Over the past decade, the decision of many doctors to continue working beyond the standard retirement age has helped to avoid an exacerbation of shortages in many EU countries. This trend is evident in the increasing proportion of doctors aged over 65 between 2012 and 2022, which has been particularly significant in countries such as Italy, the Slovak Republic, Germany, France and Belgium (Figure 1.18).
Source: Eurostat (hlth_rs_phys).
Italy stands out with 27% of its medical workforce aged 65 and over, foreshadowing substantial doctor attrition in the coming years. The outflow of doctors due to retirement in the country is expected to peak in 2025 with the retirement rate projected to return to normal levels only by 2030 (Sumai-ASSOPROF, 2023[33]). To mitigate the impact of this anticipated retirement wave, Italy has implemented measures to retain older physicians longer in the system while simultaneously boosting the training of new doctors in recent years (Figure 1.13). In 2024, legislation was passed to temporarily suspend the obligation for doctors employed by public facilities (NHS) to retire at age 70, allowing them to remain in the ward until they are 72. This legislation also enables NHS local authorities to keep medical personnel in service beyond retirement age on a voluntary basis, addressing both the serious staff shortage and the training and tutoring needs of newly hired staff. Additionally, those who have retired since September 2023 can be readmitted to service within these limits (Consiglio dei ministri, 2023[34]).
Pension reforms and a potential increase in doctors’ capacity and willingness to work longer may have a significant impact on the supply of doctors and replacement needs in the short to medium term. Many EU countries besides Italy have combined efforts to increase statutory retirement ages, curb early retirement, and offer incentives for longer working lives along with initiatives to foster job flexibility for older workers. Normal retirement ages have increased or are set to increase in most EU countries, reaching an average of over 65 years for both men and women starting their careers today. In Denmark, Estonia, the Netherlands and Sweden, the normal retirement age is projected to rise to 70 years or more if life expectancy gains materialise as projected and legislated links with life expectancy are applied (OECD, 2023[35]). Although there are few studies examining the specific impact of these pension reforms on doctors and other health workers, they can be expected to prolong the working lives and expand the supply of doctors, nurses and other health workers after age 65 in the coming years.
According to the 2023 OECD Health System Characteristics Survey, six EU countries (Czechia, Greece, Ireland, Latvia, Portugal and Spain) indicated that part of their strategies to maintain or increase the supply of doctors is to prolong their working lives. This may be achieved through general pension reforms that increase the retirement age for all workers or through more specific incentives targeting doctors to prolong their working lives.
1.6.3. Improving the remuneration of some categories of health workers can increase attractiveness and retention
An important aspect of job quality relates to earnings, as explicitly recognised under the OECD Job Quality Framework. Based on standard economic theory, wage adjustments should address any imbalance in the supply and demand for different categories of health workers: if there are shortages of some categories of workers, wages should go up to increase supply (either in terms of the number of health workers and/or their working hours) while the demand should decrease, thereby reducing the shortage. However, this supposes that wages are free to adjust to labour market conditions and that the supply of health workers is fairly responsive (or “elastic”) to wage changes. In practice, both of these conditions often do not apply in the health sector.5
The remuneration of health workers varies widely by categories of workers depending on qualification levels, years of experience (seniority), working time (or activity rates) and negotiating power. In general across EU countries, the remuneration of doctors is several times higher than the average wage of workers in all occupations reflecting their higher qualifications and longer working hours. GPs earn two to four times more than the average wage, while specialists earn two to five times more (see indicator on “Remuneration of doctors” in Chapter 7). The remuneration of nurses is substantially lower than that of doctors. On average across EU countries, it is about 20% higher than the average wage of workers in all occupations, although in some countries nurses do not earn more than the average wage (see indicator on “Remuneration of nurses” in Chapter 7). The remuneration of personal care workers is about 30% lower than the economy-wide average wage on average across EU countries (OECD, 2023[36]).
Based on data collected through the Eurofound’s EWCTS survey in 2021, over 40% of personal care workers on average across EU countries reported having financial difficulties (almost the same proportion as cleaners and cooks and waiters). Over 20% of nurses also reported having difficulties in making ends meet, slightly lower than the average across all occupations considered to be in shortage, but nonetheless a significant proportion. Only about 5% of doctors reported facing such financial difficulties on average across EU countries (Figure 1.19).
Workers in certain health occupations also believe that they were not fairly rewarded. This is notably the case for nurses: only 40% of nurses felt in 2021 that they were paid fairly in relation to their efforts and achievements on average across EU countries (19 percentage points less than the average across all occupations).
Source: European Commission (2023[18]), Employment and social developments in Europe 2023, https://data.europa.eu/doi/10.2767/089698.
Following the pandemic, nurses have obtained substantial pay rises in several EU countries, including Hungary, Poland, Slovenia, Estonia and France. However, the high inflation rates in the years that followed the pandemic eroded the (nominal) wage gains of nurses as well as other categories of workers in the health and other sectors. In several countries, the growth in the remuneration of nurses in real terms (adjusted for inflation) in the years up to 2022 was almost nil or even negative (see indicator on the “Remuneration of nurses” in Chapter 7).
1.6.4. Several countries are recruiting foreign doctors and nurses to respond to domestic needs, but this strategy raises equity and sustainability issues
Health workers can leave the health system in a country to seize better job opportunities in other countries. The mobility of several regulated health professions (including doctors and nurses) has been facilitated by the EU Directive on the recognition of professional qualifications.
Many OECD countries in Europe and outside Europe are aiming to address current shortages of health workers at least partly by recruiting them from other countries. While this can be a quick solution to address short-term domestic needs, this may only exacerbate shortages of doctors and nurses when they are recruited from countries that have a lower supply and more acute shortages of skilled health workers. The WHO Global Code of Practice on International Recruitment of Health Personnel establishes ethical principles for the international recruitment of health personnel and discourages active recruitment from countries facing critical health workforce shortages (WHO, 2010[37]).
The recruitment of foreign doctors and nurses increased greatly in many European countries in 2022 and 2023 following a temporary reduction during the first two years of the pandemic. Based on data available from 27 European countries (excluding some EU countries for which data is not available but including some of the main destination countries such as Switzerland and the United Kingdom), the recruitment of foreign-trained doctors was 17% higher in 2022 than before the pandemic in 2019, rising from about 28 000 in 2019 to 33 000 in 2022 in terms of annual inflow. The annual inflow of foreign-trained doctors continued to increase in 2023 in 11 of the 12 European countries for which data are available (Lithuania being the only exception), with a further increase of 40% compared to 2022 on average. The increase in the recruitment of foreign-trained nurses between 2019 and 2022 was even stronger, averaging about 72% across the 22 European countries for which data are available (which includes the United Kingdom and Switzerland), rising from about 26 000 in 2019 to 45 000 in 2022.
In 2023, the overall (cumulative) stock of foreign-trained doctors as a share of all doctors in the main destination countries in Europe reached over 40% in Norway, Ireland and Switzerland, although in Norway about half of these foreign-trained doctors are Norwegian students who went abroad to get their first medical degree. When it comes to nurses, the share of foreign-trained nurses among all nurses was highest in Ireland, reaching over 50% in 2023, followed by Switzerland and the United Kingdom where about 25% of all nurses were initially trained in another country (Figure 1.20). Ireland’s particularly high reliance on foreign-trained nurses stems from a combination of factors. To fill chronic staff shortages, Ireland’s Health Service Executive has conducted active overseas recruitments targeting countries like the Philippines and India, which have well-established nursing diasporas in the country (Figure 1.22). Concurrently, significant numbers of Irish-trained nurses have emigrated to other English-speaking countries, attracted by better working conditions and pay, thereby exacerbating the domestic nursing shortage and further driving the health system’s dependence on foreign-trained nurses.
Notes: The EU averages are unweighted and only include those countries with data available for both data points. The data for Germany relate to foreign nationality (not to the place of training).
Source: OECD Health Statistics 2024.
The countries of origin of foreign-trained doctors and nurses working in some of the main destination countries in Europe varies widely, often linked to the sharing of a common language, historical ties and geographic proximity. In Ireland and the United Kingdom, a major source of doctors and nurses trained abroad is from other countries where English is at least one of the official languages. There are relatively few doctors and nurses recruited nowadays from other EU countries.6 Hence, about one‑third of doctors who moved to work in the United Kingdom in 2023 came from India and Pakistan, while another 20% came from three African countries (Nigeria, Egypt and Sudan). In Ireland, Pakistan was by far the main country of origin of foreign-trained doctors recruited in 2023, followed by two African countries (Sudan and South Africa) (Figure 1.21).
By contrast, in Switzerland, nearly all foreign-trained doctors (93%) and foreign-trained nurses (98%) who have moved to work in 2023 came from EU countries, with most of them coming from three large neighbouring countries (Germany, France and Italy).
In Germany, the composition of foreign-trained doctors and nurses is more balanced between EU and non-EU countries. While the data on the annual inflows of foreign-trained doctors only cover EU countries, the data on the cumulative stock of foreign doctors in Germany show that about 40% come from EU countries while the other 60% come from non-EU countries. Considering only the inflows from EU countries, in 2022 the greatest number of foreign doctors came from Romania, Austria and Greece. Regarding nurses, the greatest number of foreign nurses who moved to work in Germany came from the Philippines, but a large number also came from the Balkans (e.g. Bosnia-Herzegovina, Serbia and Albania).
It is important to bear in mind that the inflows of foreign doctors and nurses in Ireland, the United Kingdom and Germany are partly offset by the migration of a significant number of doctors and nurses trained in these countries to other European and non-European countries. For example, a significant number of doctors from Ireland and the United Kingdom move to other English-speaking countries such as Australia, the United States, Canada and New Zealand. As noted above, a large number of doctors and nurses trained in Germany are moving to work in Switzerland.
Note: The German data only include inflows from EU countries. Based on the data on the cumulative stock, about 40% of all foreign doctors in Germany came from other EU countries in 2022, whereas the remaining 60% came from non-EU countries.
Source: OECD Health Statistics 2024.
Source: OECD Health Statistics 2024.
Some EU countries have, for many years, been important countries of origin of doctors and nurses recruited by other EU countries, raising concerns about a “brain drain” (or “care drain”). This has notably been the case for some of the EU Member States that have joined since 2004. The reduction in barriers to mobility, notably through the EU Directive on the recognition of professional qualifications, has facilitated the movement of doctors and nurses from these countries to other EU/EEA countries.
For example, following its accession to the EU in 2007, a large number of nurses trained in Romania have moved to work in other EU/EEA countries. The movement to Italy was particularly large in 2007 and the following years, but started to decrease around 2012. Looking at trends over the decade from 2012 to 2022, the annual number of nurses trained in Romania moving to work in some of the main destination countries in Europe (Italy, Germany and the United Kingdom) has decreased. There has been a notable steep reduction in the movement to the United Kingdom following the Brexit vote in June 2016 (Figure 1.23). At the same time, there has been a slight increase in the movement of Romanian nurses to other destination countries such as Switzerland.
Many Central and Eastern European countries have significantly increased the remuneration of nurses over the past decade, thereby narrowing the pay gap with Western European countries and the financial incentives to move (see indicator on the “Remuneration of nurses” in Chapter 7).
Source: OECD Health Statistics 2024.
1.7.1. Supporting innovations in healthcare delivery to optimise skills use of health workers and raise productivity
In addition to training and retention strategies aimed at increasing the supply of different categories of health workers, innovations in health service delivery designed to use more effectively the skills of different categories of health workers can also help address the shortages of some categories of doctors and nurses, and improve job satisfaction and retention rates. Previous OECD work has shown that many doctors and nurses report being over-skilled for some of the tasks they do in their daily work, indicating a waste in human capital and the possibilities to reallocate tasks to optimise skills use. This is a particular issue among nurses with higher levels of education (a Master’s degree or the equivalent) who are more likely to report being over-skilled for the job they do (OECD, 2016[2]).
In recent years, many EU countries have expanded the role and scope of practice of certain categories of nurses (often referred to advanced practice nurses) to address issues related to access, continuity and quality of care, particularly in primary care. Many countries have also introduced or expanded the roles of physician assistants (PAs) to reduce the demands and pressures on GPs and other categories of doctors.
However, the movement towards more advanced nurse practice roles in primary care is not new and started in the 1960s in the United States with the introduction of the first nurse practitioners (NPs) in some States and in Canada in response to shortages of GPs in rural and remote areas. In Europe, the United Kingdom started to use NPs and other advanced practice nurses in the early 1980s, and other countries followed such as the Netherlands in 1997, Ireland in 2001, Finland in 2003 and Estonia in 2005 (Box 1.8).
It is not easy to define precisely what is meant by “advanced practice nursing” and who is an “advanced practice nurse” as this term encompasses a large variety of educational requirements, roles, practices, and titles. A recent review by the European Federation of Nurses pointed out that the definition, recognition, regulation, and education of advanced practice nursing vary significantly across Europe (De Raeve et al., 2023[38]). The International Council of Nurses (ICN) has proposed a few years ago the following definition of advanced practice nurses and nurse practitioners:
“An Advanced Practice Nurse (APN) is a generalist or specialised nurse who has acquired, through additional graduate education (minimum of a master’s degree), the expert knowledge base, complex decision-making skills and clinical competencies for Advanced Nursing Practice… The two most commonly identified APN roles are clinical nurse specialists (CNS) and nurse practitioners (NPs).
A Nurse Practitioner (NP) is an Advanced Practice Nurse who integrates clinical skills associated with nursing and medicine in order to assess, diagnose and manage patients in primary healthcare settings and acute care populations as well as ongoing care for populations with chronic illness.” (Schober et al., 2020[39]).
Not surprisingly, the number of NPs is highest in those countries that recognised this role earlier. In the United States and Canada, the number of NPs has increased rapidly over the past decade to respond to growing demands for primary care and hospital care in a context of persisting shortages of certain categories of doctors (e.g. GPs). In Europe, the United Kingdom and the Netherlands have the highest number of NPs (who may have a different title such as “advanced nurse practitioner” in the United Kingdom or “nurse specialist” in the Netherlands). In the Netherlands, the number of NPs has increased steadily since 2010, although their role and scope of practice is more limited than in several other countries, with some functions only permitted under the supervision of doctors (Brownwood and Lafortune, 2024[40]). The Netherlands has also increasingly relied on physician assistants to support doctors, although the number of physician assistants (PAs) remains lower than NPs (Figure 1.24).
Note: Nurse practitioners refer to those working in general healthcare.
Source: ACMMP (2022[41]), Capaciteitsplan 2024‑27 [Capacity plan 2024‑27], https://capaciteitsorgaan.nl/capaciteitsplan-2024-2027-integraal-overzicht/.
The Dutch health workforce planning models have started to incorporate different vertical substitutions of tasks between doctors and these new professions to assess the impact on the projected demand and required training for these professions. In its 2022 report, the Advisory Committee on Medical Manpower Planning (ACMMP) recommended to increase the training of NPs by 7% and PAs by 10% over the period 2024‑27 to respond to future demand (Advisory Committee on Medical Manpower Planning, (ACMMP), 2022[41]).
Estonia also has a long experience of over 15 years with advanced practice nursing in primary care. In 2009, GPs were incentivised to hire a nurse in their practice by the threat of reduced reimbursement for those who did not. In 2013, GPs were further incentivised to employ a second nurse this time through an extra bonus. Nowadays, most GP practices employ at least two family nurses. Practice assistants are also part of primary care teams. Since the introduction of Family Primary Healthcare Centres in 2018, family nurses have become the usual first point of contact for patients. The nurse competences are relatively broad and include health promotion, disease prevention, and chronic disease monitoring, as well as prescriptions, procedures and health check-ups. When the nurse competences are not sufficient to address the health issues of some patients, these patients get an appointment with a GP.
The EU-funded project TaSHI (TAsk SHIfting) gathered evidence on the potential benefits of innovative ways in using the skills of different categories of health workers in delivering health services and developed tools to support implementation (Box 1.9).
Between April 2021 to March 2024, the EU-funded TaSHI project, co‑ordinated by Semmelweis University in Hungary, collected evidence and tools on task shifting practices in the health sector and provided an overview of the potential benefits of task shifting based on concrete experiences in five European countries (Estonia, Italy, Lithuania, the Netherlands and Norway).This three‑year project produced tangible outcomes to support the implementation of new task shifting initiatives, including:
A new curriculum to support task shifting in healthcare accompanied by training materials.
A guidebook on task shifting.
A set of recommendations to strengthen the resilience of the health workforce for different stakeholder groups.
Source: https://tashiproject.eu/.
1.7.2. Changing roles and opportunities for health workers in the digital and AI era
As European health systems grapple with workforce shortages and rising demand for health services, the integration of digital technologies and artificial intelligence (AI) holds promise in supporting health workers in their workflow and enhancing their productivity. Digital health tools are already enhancing health professionals’ clinical practice. A recent umbrella review indicated that novel tools currently being deployed in high-income countries have been found to generally improve healthcare providers’ performance (Borges do Nascimento et al., 2023[42]). Within the next decade, this technological transformation is poised to significantly transform the roles and responsibilities of health workers across Europe. Early signs of this transformation are already visible with novel roles emerging in recent years, such as telehealth co‑ordinators and telemedicine physicians who provide remote care enabled by the ability to track patients’ conditions at home.
Because of the specific nature and mix of tasks involved in providing health services, for most health occupations the implementation of digital technologies and AI presents opportunities for augmentation rather than outright replacement, as few roles are entirely automatable (Moulds and Horton, 2023[43]; OECD (forthcoming)[44]). Their integration is anticipated to have a multifaceted impact across all stages of the patient journey within the health system (Table 1.1). For instance, digital and AI-powered tools can streamline triage and referral management processes, reducing waiting times and improving the appropriateness of referrals (NHS England, 2018[45]). Administrative tasks carried out by clinical staff, particularly repetitive back-office processes, are prime candidates for automation, with recent estimates suggesting that up to 30% could be at least partially automated through digital solutions that can execute these tasks with greater accuracy and speed than humans (EIT Health; McKinsey & Company, 2020[46]).
The Netherlands provides a compelling example of how governments have started leveraging this potential to address healthcare challenges. Faced with a projected shortage of nearly 200 000 health and social care workers by 2033, the Dutch Government plans to harness AI in healthcare to reduce doctors’ administrative burden from 40% to just 20% of their working hours. To achieve this, the government will prioritise legislation and regulations to enable generative AI in hospital care and accelerate efforts to improve data availability and exchange in the healthcare and welfare sectors (Government of the Netherlands, 2024[47]).
AI-powered tools can also analyse patients’ data in real-time to support clinical decision-making, allowing clinical staff to focus more on patients and improve the quality and efficiency of care delivery. In diagnostic roles like radiology and pathology, AI can assist in analysing medical images and identifying patterns that may be difficult to discern through manual analysis (Barragán-Montero et al., 2021[48]).
The integration of digital technologies and AI in healthcare holds great potential for augmenting staff capabilities and productivity, but also poses challenges
While digital technology and AI tools offer significant potential for enhancing health professionals’ capabilities, their integration also presents challenges and risks that require careful management. A primary concern is the risk of sub-optimal implementation, where the deployment of these advanced technologies fails to align with the practical demands and operational difficulties of day-to-day clinical practice – a potential misalignment which can further burden an already stretched clinical workforce. To mitigate these risks, it is crucial to invest in comprehensive reskilling and upskilling programmes enabling health workers to gradually transition into their evolved roles. This may involve training in data analysis and systems management, as well as in soft skills such as communication, as these novel technologies are bound to transform the nature of physician-patient interactions in ways that remain uncertain (Mittelstadt, 2021[56]). In addition to these adaptations, health workers will need to develop a comprehensive set of digital and data literacy skills. Equally crucial is a thorough understanding of data privacy and security practices to ensure the responsible and ethical use of sensitive patient data. These competencies are not just technical requirements but are fundamental to maintaining patient trust and ensuring high-quality care in an increasingly digitised healthcare environment.
To address these evolving skill requirements, collaboration between healthcare organisations, universities and industry is essential in developing comprehensive training programmes. Such initiatives might include, among other elements, integrating AI-specific content into medical and nursing curricula; ensuring that new graduates enter the workforce with a solid foundation in digital health technologies and health data management; offering continuing education opportunities for practising professionals to stay up-to-date with rapidly evolving AI applications in healthcare; and creating interdisciplinary career paths at the intersection of healthcare, data science and AI, with a view to nurturing talent capable of driving best practices and ensuring the seamless integration of novel technologies into frontline clinician workflows.
Another related challenge is the potential for emerging digital technologies and AI to alter the nature of healthcare work in unexpected ways, potentially leading to reduced job satisfaction. For instance, while automation of routine administrative tasks enables health professionals to maximise time spent on specialised care work, continuous engagement at peak cognitive capacity may paradoxically increase stress levels and burnout risk (Moulds and Horton, 2023[43]).
These complex dynamics highlight the need for careful consideration when implementing AI solutions in healthcare settings. To address these concerns, fostering a culture of collaboration between health professionals and technology experts is essential. Crucially, health workers should be involved in the design and implementation of these capacity-augmenting technological tools to make sure that their insights are leveraged to create efficient solutions that enhance rather than inadvertently undermine their professional roles. Similarly, health informatics experts should be recognised as key contributors, given their expertise in building and maintaining integrated digital health infrastructures, designed to complement and enhance front-line clinician workflows.
Digital health technologies hold promise to enhance patient involvement in their own health management
The increasing availability of heath data through digital health tools, such as mobile apps, wearables and patient portals is empowering patients to take a more active role in managing their own health. By providing patients with secure access to their health records and personalised health metrics, these tools effectively activate millions of additional “health workers” able to track routine health conditions with co‑ordinated intervention and engage the health system more efficiently.
For example, AI-powered chatbots and virtual health coaches can provide patients with 24/7 access to health information, triage symptoms, and guide them to the appropriate level of care (Iqbal, Celi and Li, 2020[57]). Remote monitoring devices can help patients with chronic conditions track their vital signs and symptoms at home, alerting healthcare providers when intervention is needed (Shaik et al., 2023[58]), and digital therapeutics, such as mental health apps, can extend the reach of care beyond traditional clinical settings, supplementing the work of mental health professionals (Graham et al., 2019[54]).
The increasing adoption of patient-facing digital health tools has the potential to alleviate some of the burden on the health workforce and mitigate the impact of staff shortages. However, realising these benefits will require careful planning, targeted investments in a fully data‑enabled health environment, and a focus on ensuring equitable access and digital literacy for all patients.
Despite a steady increase in the number of doctors, nurses and other health workers over the past few decades, the European health workforce is facing a severe crisis with most countries grappling with significant shortages of several categories of health workers due to growing demand for healthcare as well as a reduction in the working hours of some categories of health workers aiming to achieve a better work-life balance. These workforce shortages may be exacerbated in the coming years, driven by the double demographic challenge of an ageing population and an ageing health workforce, posing a serious threat to the sustainability and resilience of European health systems. As the proportion of the population aged 65 and over in the EU is projected to increase from 23% in 2023 to nearly 30% by 2050, the demand for health services is expected to increase as well. However, this rising demand may be contained by individual and policy actions to promote healthy ageing, and health workforce productivity improvements can also mitigate the impact on the demand for health professionals. On the supply side, large numbers of health professionals are approaching retirement age in a significant number of EU countries, requiring a substantial inflow of new health professionals to replace them, as well as more flexible work-to-retirement options to retain those who are able to work longer.
This chapter has examined the complex interplay of factors shaping the supply and demand for health workers in the EU. The analysis has revealed worrying trends, such as high levels of job dissatisfaction and burnout among current health workers, exacerbated by the COVID‑19 pandemic, and declining interest in health careers among young people. Addressing health workforce challenges will require a multi-faceted approach, with some policies having impact in the short term, while the impact of other policies may be felt more in the medium to longer term.
Increasing the training and education of new doctors and nurses is crucial, and most EU countries have already recognised this need. However, the declining number of applicants to nursing programmes in some countries underscores the urgency of making nursing and other health careers more attractive. Improving the working conditions and remuneration of health workers – in other words improving the quality of work – is an essential first step to boost both attractiveness and retention rates of current workers and prevent a vicious cycle of shortages leading to increased workloads, stress, and further attrition.
The chapter has shed light on the growing role of international migration of health workers in Europe as part of the strategies that many countries are using to address health workforce shortages. While the recruitment of foreign-trained health professionals can provide a quick fix to domestic needs, overreliance on this approach is inefficient and will exacerbate shortages in countries of origin while creating vulnerabilities in the health systems of destination countries. As the demand for healthcare continues to grow, it is crucial for EU countries to strike a balance between leveraging the benefits of intra-EU worker mobility and ensuring the sustainability of their domestic health workforces. To achieve this, better data on health worker movement within Europe is essential for monitoring cross-border flows and informing the development of co‑operative policies.
Increasing the training and improving the working conditions of health workers will be key in addressing the growing domestic need and demand for healthcare, but it will come with a significant financial burden. Prior OECD estimates indicate that bolstering the health workforce to make health systems more resilient would require significant additional resources relative to the pre‑pandemic level, amounting to an average of 0.6% of GDP across the EU (OECD, 2023[1]). While this cost is undoubtedly substantial, it pales in comparison to the economic and societal repercussions of having fragile health systems that fail to deliver adequate care, as the pandemic has vividly illustrated. Investing in a robust, well-trained, and motivated health workforce is therefore a prudent economic strategy to ensure the long-term sustainability and effectiveness of health systems.
However, relying solely on an indefinite increase in the number of doctors, nurses and other health workers is unlikely to be feasible or sufficient in meeting the future demand for health services, especially in countries that already have some of the highest densities of health professionals. In conjunction with workforce expansion, it is thus essential to explore innovative solutions that can enhance the productivity and efficiency of healthcare delivery. This includes scaling up research and investment in digital health technologies and artificial intelligence that can augment the capacity of health workers and streamline administrative tasks. Experimenting with new models of care provision enabled by digital technology and task sharing can also help alleviate the burden on doctors and nurses and increase productivity while improving access to care. Modernising the curricula of medical and nursing education programmes to incorporate digital literacy and interprofessional collaboration skills is another essential step to prepare the health workforce for the challenges and opportunities of the digital health era.
The health workforce challenge in the EU is a complex and pressing issue that requires urgent and comprehensive action. The decisions and investments made now will have far-reaching consequences for the resilience and sustainability of European health systems in the coming decades. Against this background, the EU has a crucial role to play in supporting Member States in their efforts to attract, train, and retain a sufficient number of skilled and motivated health workers. By fostering collaboration and leveraging its funding instruments, the EU can help create a more resilient and equitable European Health Union that ensures timely access to high-quality healthcare for all its citizens. The grit and dedication displayed by health workers during the pandemic and beyond must be matched by policies to address the root causes of the workforce shortages and build a health system that can withstand the demographic challenges ahead.
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← 1. The trend analysis for nurses is limited to the last decade only because there are breaks in the time series for several countries in the preceding years.
← 2. It is important to bear in mind that data on all job vacancies do not provide a precise indicator of shortages. Instead, they serve as an indicator of employers’ interest in recruiting new staff, but not whether they encounter difficulties in doing so.
← 3. The internationalisation of medical education also complicates the analysis of the “brain drain” in those countries that are attracting a significant number of international students, when the “brain drain” is measured based on the place where doctors have obtained their initial medical degree.
← 4. Data from professional registrations might be used as an alternative to measure the number of health professionals who decide to leave the profession, but an important limitation is that these professionals will often wish to keep their professional registrations as long as possible in case they might want to rejoin the workforce or because they perceive some other potential benefits in keeping their registration.
← 5. A key characteristic of health labour markets in many countries is the “monopsony” power exercised by the dominant public purchaser on the wages/fees paid to doctors, nurses and other health workers. In NHS systems, governments often play a central role in wage setting as the pre‑eminent funder of jobs in the health sector, and pay rates are often based on nationally agreed pay structures (or sub-nationally in federal countries and other countries where responsibility for healthcare delivery rests with sub-national governments/authorities). The wages/fees may be fairly rigid and not responsive to local labour market conditions. In addition, the supply of doctors, nurses and other health workers may not be very elastic to changes in wages for at least two reasons. First, it takes several years to train new doctors, nurses and other skilled health workers, so in the short-term any change in supply can only come either from inactive workers (e.g. nurses) deciding to return to work, current workers choosing to work more hours (in return for higher hourly wages/fees) or increased recruitment of foreign-trained workers (attracted by higher pay). Second, the impact of pay increases on the supply of labour among current health workers is not clear and may not be linear: it is possible that a “substitution” effect (i.e. a preference for more leisure over work) might reduce the elasticity of supply above a certain wage/income threshold.
← 6. The number of doctors and nurses moving to the United Kingdom from other EU countries fell in the mid‑2010s, coinciding with both the Brexit vote and the introduction of language tests by UK professional regulators.